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Orthopedic Diagnostics > Shoulder Assessment > Flashcards

Shoulder Assessment Flashcards

1
Q

Two main categories for MOI for shoulder injury. What kinds of pathology would you see under each?

A

MOI: insidious or traumatic

i. Traumatic – often indicates sprains/strains, labral pathology
ii. Insidious – most often postural or activity (repetitive) related. (Possibly referral from Csp)

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2
Q
A
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3
Q

Other than MOI what other things should you ask about in history for shoulder pathology?

A
  • Ask about feelings of instability, areas of apprehension?
  • Are there specific movements that increase pain? This may give information on what structures are causing the pain.
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4
Q

If cross flexion movement hurts what might we suspect is injured?

If there is pain in the “painful arc” range of 60-120 degrees what might we suspect?

A
  • If cross-flexion movement hurts we are going to examine the AC
  • Painful arc more indicative of GH joint issues and/or pinching under the acromion, esp. supraspinatus, long head of biceps, subacromial bursa
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5
Q

What nerve roots innervate the suprascapular nerve?

What nerve and nerve roots innervate the rhomboids and levator scapula?

A

Note: Can get referral pain into shoulder from cervical spine.

Suprascapular nerve C5 and C6 and little C4

Rhomboids and levator scapula are innervated by dorsal scapular nerve but same nerve roots of C4,5,6.

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6
Q

Which spinal segments in the C-spine break down the quickest?

A

C4, C5, C6 spinal segments break down quickest and is where you get referral pattern. It will start interfering with muscle function and giving anterior shoulder pain.

If it looks like impingement but treatment of shoulder is not helping maybe look at neck

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7
Q

If the person says pain and movement is better in teh upper ranges of motion what might we think of?

If there is lack of strenght but it is not painful what might this mean?

If there is pain and limitation as well what does this mean?

A

If they say it is better in upper ranges of motion you are thinking of impingement, rotator cuff tears.

Lack of strenght but not painful, this is inhibition of nerves.

Pain and limitation some degree of rotator cuff tear. Is it posturally induced? Is it repetitive and chronic? Or was there a traumatic incident?

Rotator cuff tears – lack of blood supply, esp supraspinatus, very rarely surgically repaired unless you are under 30 or 40.

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8
Q

In regard to distal symptoms with pain referring down the arm, what is the relationship between distance travelled down the arm and likelihood that it is a neurological issue from the neck?

A

Distal symptoms, if anything is referring down the arm, the further down it goes the more likely it is neurological from the neck. Nerve conduction tests.

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9
Q

If pain is going past the elbow what tests should be done?

A

If pain going past the elbow check:

  • myotomes
  • dermatomes
  • reflexes
  • Spurling’s compression/distraction
  • upper limb nerve tension tests
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10
Q

If there is pain in the deltoid region that is not from a local injury where is this likely referring from?

A

Deltoid C5 referral pattern (policeman’s badge)

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11
Q

What are we looking at in terms of observation for shoulder injuries?

A
  1. General, overall posture – head forward, ant rotated shoulders, location of hands, shoulder heights.
  2. How does the patient hold the upper limb? Is it supported?
  3. Any deformity (step deformity, sulcus signs), bruising, muscle atrophy

Step deformity – AC separated from humerus

Sulcus – pull on arm and a dip forms in shoulder because it is pulling out a little bit, slightly dislocating

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12
Q

If you see wasting in the supraspinatus and infraspinatus muscles what might you suspect?

A

Suprascapular nerve pinched – see wasting in supraspinatus and infraspinatus

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13
Q

Should always assess the thoracic spine along with the shoulder. What would you look for in the thoracic area? (Hint: think t-spine and scapula)

A
    1. Note position of the scapula on the thoracic wall*
      i. Distance from spinous process
      ii. Angle of scapulae on thoracic wall
      iii. Winging of scapulae
    1. Tsp posture – normal kyphosis?*
      i. decreased kyphosis (flat) ?
      ii. increased/hyper kyphosis ?
      iii. scoliosis ?
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14
Q

If the inferior angle of the scapula is sticking out and the scapula is tilted forward what imbalance is likely present?

A

Pec minor tightness causes this

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15
Q

If the medial scapular border is winging what imbalance is present?

A

Medial scapular border winging is usually because of weakness in rhomboids not holding it down and/or serratus anterior being dominant/too tight. Can have one or the other or both combined.

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16
Q

If the scapula wings out severely during dynamic movement what is likely occurring?

A

Long thoracic nerve that innervates serratus anterior is not functioning properly

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17
Q

What are the AROM degrees for shoulder for the following:

i. Elevation through flexion
ii. Elevation through abduction
iii. Elevation through scaption
iv. Note: the GH joint only has ___ degrees of forward elevation, the other ___ comes from the scapulae.

A

AROM degrees for shoulder

  1. Elevation through flexion (160-180 degrees)
  2. Elevation through abduction (170-180 degrees)
  3. Elevation through scapular action (170-180)
  4. 120 degrees GH joint, other 40 degrees from scapula
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18
Q

What are the AROM degrees for the shoulder for the following:

Lateral/external rotation

Medial/internal rotation

Extension

Horizontal adduction/cross flexion

A
  1. Lateral/external rotation 80-90 degrees
  2. Medial/internal rotation 60 - 100 degrees
  3. Extension 50-60 degrees
  4. Horizontal adduction/cross flexion 130 degrees
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19
Q

Other than degrees of range of motion, what else should be noted about the range?

A

Not only should range be noted, but the quality of range. Often the shoulder “hikes” to assist painful elevation or “jogs, hitches or jumps “ with loss of scapular control. Painful arcs are very common in shoulder pathology and should be looked for.

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20
Q

What is the “painful arc” when it comes to the shouler?

A

Pain in the shoulder while abducting from 60-120 degrees.

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21
Q

At 45-60 degrees abduction how are the structures under the acromion affected?

A

< 45-60 degrees: The structures under the acromion are typically not compressed

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22
Q

At 60-120 degrees how are the structures under the acromion affected?

A

60-120 degrees: these structures (subacromial bursa, rotator cuff tendons, LHBT) become increasingly more compressed. Need proper biomechanics of the GH joint to avoid compression.

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23
Q

At greater than 120 degrees how are the structures under the acromion affected?

A

> 120 degrees: these structures have passed under the acromion process and are no longer being pinched thus the pain goes away.

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24
Q

If there is pain at greater than 170 degrees of shoulder abduction what is likely occuring?

A

>170 degrees: Pain here is indicative of AC joint involvement.

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25
Q

In terms of forward flexion of the arm, when looking at the GH painful arc, what is occuring below 45-60 degrees?

A

Below 45-60 degrees, nothing being compressed too much, supraspinatus activating to depress humeral head

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26
Q

In terms of the GH joint painful arc of shoulder flexion, what is occuring at 60-120 degrees? What about after 120 degrees?

A

60 degrees, humeral head has depressed into axillary pouch of shoulder capsule and arm is allowed to elevate. If you don’t have that downward rotation of humeral head you will get impingemnet. Structures like subacromial bursa, rotator cuff tendons, biceps tendon, capsule itself becoming more affected.

At 120 degrees humerus swings out and clears acromion so pain goes away

27
Q

What are the end feels for PROM for the following movements?

i. Elevation through flexion
ii. Elevation through abduction
iii. Elevation through scaption
iv. Lateral/external rotation
v. Medial/internal rotation
vi. Extension
vii. Horizontal adduction/cross flexion

A
  1. Elevation through flexion - tissue stretch
  2. Elevation through abduction - bone to bone or tissue stretch
  3. Elevation through scaption - bone to bone or tissue stretch
  4. Lateral/external rotation - tissue stretch
  5. Medial/internal rotation - tissue stretch
  6. Extension - tissue stretch
  7. Horizontal adduction/cross flexion - soft tissue approximation or tissue stretch
28
Q

Resisted isometric movements for the shoulder flexion would target which muscles? Extension?

A
  • Flexion* - anterior deltoid, long head bicep brachii, coracobrachialis
  • Extension* - posterior deltoid, tricep
29
Q

Resisted isometric movements for shoulder abduction would target which muscles? Adduction?

A

Abduction - middle deltoid, supraspinatus

Adduction - Pec major, latissimus, teres major

30
Q

Resisted isometric movements for cross flexion/internal rotation would target which muscles? What about external rotation?

A
  • Cross flexion / Internal rotation* - subscapularis, latissimus, teres major, pectoralis major
  • External rotation* - infraspinatus, teres minor
31
Q

What is the main shoulder flexor? What is the main shoudler extensor?

A
  • Anterior deltoid is the main shoulder flexor.
  • Posterior deltoid is main shoulder extensor.
32
Q

If you have long head biceps tendinopathy what movement will cause the most pain?

What shoulder motion is the weakest and why?

A
  • Long headed biceps tendinopathy will get pain with flexion.
  • External rotation usually weakest because only rotator cuffs can do this. With the other movements some of the other big muscles can compensate.
33
Q

If symptoms decrease with passive elevation of the scapula, what muscles are weak?

A

upper fibers of trapezius are weak

34
Q

If symptoms decrease with passive medial slide of the scapula what muscle fibers are weak?

A

lower fibers of trapezius are weak

35
Q

If symptoms decrease with passive posterior tilt (pushing down inferior angle) of the scapula what muscle is imbalanced?

A

Pectoralis minor is too tight

36
Q

If rotator cuff strenth improves significantly with scapular correction what does this mean?

A

Primary problem is with scapular control and not the rotator cuff

37
Q

If you suspect a shoulder impingment what cluster of tests could you do? How many would need to be positive to diagnose impingment?

A
  1. Empty Can test
  2. External Rotation Weakness
  3. Hawkins-Kennedy test
  4. Neer Impingement test
  5. Painful Arc

3 or more positive is sufficient to diagnose impingement.

The Apprehension-Relocation Test (pg 192) can also be useful.

38
Q

How do you perform the Empty Can Test? What other conditions might result in a positive empty can test?

A
  1. Patient elevates arms to 90 degrees abduction with thumbs up (full can)
  2. Examiner provides downward pressure on arms and notes patient’s strength
  3. Patient elevates arms to 90 degrees and horizontally adducts 30 degrees (scapular plane) with thumbs pointed down as if emptying a can.
  4. The examiner provides downward pressure on the arms and notes the patient’s strength
  5. A positive test for rotator cuff tear is examiner assessment of more weakness in teh empty can position vs. the full can position, patient complaint of pain, or both.

This test checks for supraspinatus strength, rotator cuff tear, and all stages of impingment syndrom from bursitis through rotator cuff tear

39
Q

Describe how to perform the External Rotation Lag Sign (External Rotation Weakness test). What does this test for?

A
  1. The patient is seated with examiner standing to the rear
  2. The examiner grasps the patient’s elbow with one hand and the wrist with the other.
  3. The examiner places the elbow in 90 degrees of flexion and the shoulder in 20 degrees of elevation in the scapular plane
  4. The examiner passively externally rotates the shoulder to near end range
  5. The examiner asks the patient to maintain this position as the patient’s wrist is released
  6. A positive test for supraspinatus/infraspinatus tear is indicated by a lag that occurs with the inability of the patient to maintain their arm near full external rotation.

This test checks for torn rotator cuff and impingement, more specifically a supraspinatus/infraspinatus tear.

40
Q

Describe the steps of the Hawkin’s/Kennedy test. What does it test for?

A
  1. The patient is seated while the examiner stands anteriorly to the involved shoulder
  2. The examiner first raises the patient’s arm into approx. 90 degrees of shoulder flexion or abduction wih one hand while the other hand stabilizes the scapula, typically superiorly. (Nadine says not to worry so much about the scapula stabilization)
  3. The examiner applis forced humeral internal rotation in an attempt to reproduce the concordant shoulder pain. If concordant shoulder pain is present the test is positive.

This test for subacromial impingement, subacromial bursitis, rotator cuff tear, and superior labral tear.

41
Q

Describe the steps of the Neer Impingement Test. What does it test for?

A
  1. The patient is seated while the examiner stands to the side of the involved shoulder
  2. The examiner reaises the patient’s arm in flexion with one hand while the other hand stabilizes the scapula
  3. The examiner applies forced flexion toward end-range in an attempt to reproduce the shoulder pain
  4. If concordant shoulder pain is present the test is positive

The test checks for subacromial impingement, subacromial bursitis, rotator cuff tear and superior labral tear (not great for labral tear diagnosis though)

42
Q

Describe the steps for the Painful Arc test. What does it test for?

A
  1. The patient is standing. The examiner faces teh patient to observe shoulder motion
  2. The patient is instructed to actively abduct the involved shoulder
  3. A positive test is indicated by patient report of concordant pain in the 60-120 degree range. Pain outside of this range is considered a negative test. Pain that increases in severity as the arm reaches 170-180 degrees is indicative of a disorder of the AC joint

This is a test for all stages of subacromial impingement.

43
Q

What cluster of test can be used to assess a rotator cuff tear?

A
  1. Active abduction < 90 degrees
  2. Drop test
  3. Empty Can Test
  4. External Rotation Lag Sign (ERLS)
  5. Hawkin’s Kennedy Test
44
Q

What is the cluster of test for a labral tear?

A
  1. Active Compression test/O’Brien’s test
  2. Apprehension Test
  3. Relocation
  • Hawkin’s Kennedy Test can also pick up a labral tear)
  • Sulcus Sign can also rule in a superior labral tear.
45
Q

How do you perform the Active Compression Test (O’Brien’s)? What does it test for?

A
  1. The patient is instructed to stand with their involved shoulder at 90 degrees of flexion, 10 degrees of horizontal adduction and maximum internal rotation with the elbow in full extension. The examiner stands directly behind the involved shoulder.
  2. The examiner applies a downward force at the wrist of the involved extremity. The patient is instructed to resist the force.
  3. The patient resists the downward force and reports any pain as either “on top of the shoulder” (AC joint) or “inside the shoulder” (SLAP lesion)
  4. The patient’s shoulder is then moved to a position of maximum external rotation and the downward force is repeated.
  5. A positive test is indicated by pain or painful clicking in shoulder internal rotation and less or no pain in external rotation.

This tests for a labral tear, SLAP lesion, labral abnormality, or AC joint pathology.

46
Q

How do you perform the Apprehension Test? What does it check for?

A
  1. The patient is either standing or supine. The examiner stands either behind or at the involved side of the patient.
  2. The examiner grasps the wrist with one hand and maximally externally rotates the humerus with the shoulder in 90 degrees of abduction.
  3. Forward pressure is then applied to the posterior aspect of the humeral head.
  4. A positive test for anterior instability is indicated by a show of apprehension by the patient or a report of pain.

This test checks for anterior instability, all instabilities of the GH jiont, labral tear, SLAP lesion.

47
Q

Describe the steps of the Apprehension-Relocation Test. What does this test for?

A
  1. The patient assumes a supine position. The examiner stands beside the patient.
  2. The examiner pre-positions the shoulder at 90 degrees fo abduction and then grasps the patient’s forearm and maximally externally rotates the humerus.
  3. If the patient displays apprehension or reports pain, a posterior force is then applied the proximal humerus.
  4. A positive test for anterior instability is indicated by a decrease in the pain or apprehension whereas no change in pain symptoms indicates impingement.

This tests for anterior instability, labral tear, SLAP lesion and impingement.

48
Q

What tests can you do to assess the acromioclavicular joint?

A
  1. Neer Impingement Test
  2. Cross Body Adduction Test
  3. Painful Arc
49
Q

How do you perform the Cross Body Adduction Test? What does it test for?

A
  1. Patient assumes a sitting position. The patient is instructed to elevate the arm to 90 degrees of shoulder flexion.
  2. The examiner stands in front of the patient and horizontally adducts the patient’s arm to end range, maintaining flexion at the shoulder.
  3. If shoulder pain is present the test is positive.

Tests for subacromial impingment and AC joint damage.

50
Q

What is a muscle test you could do for a suspected subscapularis tear? How do you perform it?

A

Lift off Test

  1. The patient is seated with affected arm behind their back.
  2. The patient is asked to lift their arm off their back.
  3. A positive test for subscapularis tear is indicated by inability of the patient to lift the arm off the back.
51
Q

What test could be done to assess inferior instability of the shoulder? How do you perform it?

A

Sulcus Sign (Feagin’s Test)

  1. The patient assumes a sitting position. The examiner stands behind the patient.
  2. The examiner grasps the elbow and pulls down creating an inferior traction force.
  3. The examiner notes, in cm, the distance between the inferior surface of the acromion and the superior portion of the humeral head.
  4. The examiner repeats the test in supine with the shoulder in 20 degrees of abduction and 20 degrees forward flexion while maintaining neutral rotation.

This test checks for inferior laxity and rules in a superior labral tear when positive.

52
Q

What tests could be done to check for posterior instability? How do you perform it?

A

Posterior Drawer Test or Push/Pull Test

  1. The patient assumes a supine position. The examiner stands beside the patient to the side of the involved shoulder.
  2. The examiner secures the distal arm of the patient in their axillary region.
  3. The examiner’s hands are placed so that the upper arm is stabilized.
  4. The examiner abducts the patient’s arm to between 80-100 degrees and then applies an anterior-to-posterior force to the humerus. The examiner carefully notes the amount of translation of the GH joint comparied to the uninvolved shoulder.
  5. Looking for pain, excessive translation, clunking or suctioning noise.

This test asesses posterior laxity and could also pick up a torn posterior labrum.

Note: Push Pull Test is essentially the same thing but you are pulling up on the wrist at the same time as you are pushing down on the humerus.

53
Q

What test could be done to pick up anterior instability in the shoulder?

A

Apprehension Test (see labral tear cluster)

54
Q

What is the reflex test for C4?

A

Levator scapula reflex

55
Q

What nerve roots are involved for the biceps reflex? Brachioradialis?

A

Both C5, C6

56
Q

What nerve roots are involved for the triceps reflex?

A

C6, C7

57
Q

Which sinew channels are most involved in shoulder pathology?

A

Small Intestine

Large Intestine

58
Q

What are the main conditions for Small Intestine Sinew channel?

A
  • Temporal headaches
  • Tinnitus
  • TMJ and ear pain
  • Rotator cuff pathology
  • Ulnar nerve radiculopathy
59
Q

\What are the main myofascial conditions for the San Jiao Sinew channel?

A
  • Pain and spasm along the channel pathway
  • Lateral epicondylosis
  • C7 radiculopathy
  • Curled tongue
60
Q

What are the main myofascial conditions for the Large Intestine Sinew channel?

A
  • Acromioclavicular joint sprains.
  • Band headaches
  • General pain, spasm and motor impairments of the shoulder and neck
  • Peri-scapular pain
  • Sinus issues
61
Q

What are the main conditions for Heart Sinew channel?

A
  • Angina, chest pain
  • Hiatus hernia
  • Mastitis
  • Medial epicondylitis
62
Q

What are the main conditions for the Pericardium Sinew channel?

A
  • Carpal tunnel
  • Chest pain
  • Dyspnea
  • Medial epicondylitis
63
Q

What are the main conditions for the Lung Sinew Channel?

A
  • C6 radiculopathy
  • Intercostal pain
  • Hemoptysis
64
Q
A

Orthopedic Diagnostics (10 decks)

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